An 86 year old male presented to a community hospital with syncope. He had documented syncope in the past felt to be related to chronic orthostatic changes but still remained on beta blocker therapy. He suffered enough trauma to result in head injury, finger dislocation and rib fractures. Abdomen was quiet. After attending to his immediate injuries, reducing the finger dislocation and getting a CT head, we undertook a FAST scan. He had pristine vitals. On scanning the abdomen, there was a very small aorta but at the umbilicus no bifurcation was seen. More distally, though, at the pelvis, a cystic round structure appeared, somewhat contiguous to the bladder, but past the point where you would have expected the bifurcation to be. The patient was admitted overnight and the hospitalist was contacted to resume care in the morning. Would you have accepted this admission or would you have asked for AAA to be ruled out by CT, given the FAST findings? Screening labs were normal.
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Had he ever had a CT scan before? What other investigations done for syncope in the past? It sounds like you weren’t too suspicious that this was a distal AAA… I think if vitals were stable, no free fluid (although it seems like the sensitivity of this is fairly low) and the patient seemed otherwise okay I would wait to do the CT in the morning to get a better idea of what that mass is.
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It was a tough decision. The US was likely a false positive since he looked well from a vascular perspective. There was no CT in house. In the end a judgment call had to be made and the imaging was deferred till the AM. There was no AAA, rather a large bladder diverticulum. However, things can change very quickly in these patients. If CT or a vascular consult can be arranged easily one should not defer with this diagnosis. It is better to be told off by a surgeon or radiologist for a false positive bedside US than to have a lost life on your conscience. If you do defer the dx make sure you do everything you can to be sure there is no indicator that you are missing i.e. epigastric pain, pulsatile mass, hypotension, pulse difference, flow issues, extremity cyanosis etc.
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It sounds like this patient suffered multiple injuries, perhaps enough to have warranted an admission anyway. If that was the case, thenI would have let the hospitalist know of this incidental finding alongside the admitting diagnosis, and ensure that the mass was appropriately imaged during his inpatient stay.
However, if this patient was otherwise fit to be discharged from the ED, I would at a minimum keep him in the department until the am as well, and speak to the radiologist to get further direction.
Unusual or incidental findings on point-of-care ultrasound open up a real can of worms. In my introductory course, we had a few cases where patients had some unusual findings on their abdominal scans – when we asked what these findings were, the reply was “it doesn’t matter.” For answering our binary questions of interest on the abdominal scan, it truly doesn’t matter – but it is still hard to ignore when it happens in real life, and even more so when you suspect that it may be contributing to their presenting complaint.
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